Artículo Clínico

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Surgical treatment of dental malpositions
Tratamiento quirúrgico de las malposiciones dentales

 

A. Jiménez Burkhardt¹, R. Fernández-Valencia Caballero², F. Pérez Fernández²,
N. Toquero de la Torre², M. Travesí Idañez²

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Abstract: We present the results obtained during our 17 years of experience in surgical treatment of dental malpositions. We include the autotransplantation of embedded molars, autotransplantation of retained canines and the repositioning of malpositioned incisors, canines and premolars; A total of 81 teeth, 60 autotransplanted and 21 repositioned, with a large degree of success. Detailed explanation is given regarding the surgical indications, techniques and results. In view of this, a conclusion is reached regarding the high, long-term success rate of surgical manipulation of embedded, healthy teeth. Key words: Dental autotransplantation; Dental repositioning; Embedded teeth.

Resumen: Presentamos los resultados obtenidos tras 17 años de experiencia en el tratamiento quirúrgico de las malposiciones dentales. Se incluyen los autotrasplantes de molares incluidos, autotrasplantes de caninos retenidos y reubicación de incisivos, caninos o premolares mal posicionados; 81 piezas dentales en total, de los cuales 60 dientes corresponden a autotrasplantes y 21 a reubicaciones, obteniendo un alto porcentaje de éxito. Se explica en detalle las indicaciones, técnica quirúrgica y resultados, concluyendo en que a la vista de los mismos, la manipulación quirúrgica de dientes retenidos sanos tiene un alto porcentaje de éxito a largo plazo. Palabras clave: Autotrasplante dental; Reubicación dental; Dientes retenidos.

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1 Médico Estomatólogo, Cirujano Oral y Maxilofacial
2 Licenciada en Odontología
Granada, España

Correspondencia:
Clínica Alberto Jimenez Burkhardt
C/ Dr. Buenaventura Carreras nº 11
Apdo. 18004 Granada, España
E-mail: alberto@clínica- ajb.com

 

Introduction

Re-implantation and transplantation of teeth has been practiced for centuries, but it has generally failed due to healing complications.

In 1771 John Hunter (forerunner of dental re-implantations and transplantations) demonstrated how a human tooth heterotransplanted in the crista galli would fix itself to either side of the crest by means of vessels, similar to the way in which a tooth is joined to gums and alveoli.¹ In 1915 Widman described the technique of implants and dental transplantations and following this, in 1948 and 1951, Apfel and Millar investigated the etiology and pathogens of root re-absorption.

The large number of investigations that have been carried out over the last 30 years with regard to the healing processes of pulp wounds, the periodontium and their relationship with infection, as well as the advances which have been so important in diagnostic tools such as the high resolution optical microscope and radiological apparatus (RVG), have turned dental re-implantations and transplantations into generally reliable and predictable clinical procedures. Shulman claimed that a transplanted tooth could last as long in the mouth as a normal tooth, if there was no occurrence of rhizolysis. Therefore, why are we currently disposining of so many healthy, extracted teeth?

There are few publications in this respect and it was based on the knowledge of professor Andreasen, master and promoter of this concept, that we have we have carried out our work. In this report we set out the results obtained following the transplantation and repositioning of numerous teeth.

Material and method

The object of this report is to share the knowledge we have acquired over the last 17 years. We suggest the indications for, and comment on the different surgical techniques, we discuss their different aspects and present our results. We do this in order to stress that these proceedings are completely predictable, and that from a scientific point of view, they should be chosen over other traditional treatments, and that it is only because of unfamiliarity that they are not.²

During this period, we have surgically moved more than a hundred teeth, and for this reason we have generically called this technique: surgical orthdontia.

Before proceeding, defining the terminology exactly of each type of intervention is necessary so as to be able to classify them and avoid confusion. We will therefore proceed to define the following concepts.

• Dental re-implantion. Placement of a tooth in its alveolus, following avulsion through traumatic injury.

• Dental repositioning. Surgical movement of a badly positioned tooth (or more), in order to place it in a suitable location in the arch.³

• Dental autotransplatation. Extraction of a permanently embedded or impacted tooth, creating a «new socket », and placement of the tooth in its new position.

We have preferred to concentrate our study on programmed dental movements in our clinic, although we will give some general guidance on what course to follow with an avulsed tooth, although injured patients tend to go to hospital centres.

In the last five years, bibliography related to tooth loss has been more in accordance with the boom in the orthodontic and prosthetic section, closely linked to aesthetic appearances. We considered the possibility of using embedded teeth to occupy these empty spaces, of handling them adequately and of showing that, in this field, this is the technique of choice providing patients have been adequately selected.

In the last 17 years we have carried out over one hundred interventions in our clinic, 80 of which have been documented and which have been very successful. Follow-up protocol was based on a 2-year period following surgery in all cases.

Surgical Indications and patient selection⁴

Autotransplantation of canines

Age. Ideal patients are those aged between 15 and 30. In younger patients, with permanent dentition and open apexes, autotransplantation is recommended, as revascularization is favoured. We have all had our failures with older patients and we feel that this is due to problems with periodontal and apical revascularization.

Location. High canines with a degree of inclination which, with conservative treatment, would have a gloomy prognosis.

Occlusion. sufficient space between teeth to allow repositioning of the canine and a favourable location with antagonists so that avoid occlusal interference is avoided.

Orthodontia. candidates are those patients who for aesthetic reasons, or for time of economic reasons, reject conservative treatment.

Molar-premolar autotransplantation^5,6

• Age is not such a determining factor as with canines, as although we have carried out very few cases in people who are about 40 years old, we have had no failures. Technically it is the easiest operation that we do.

• Absence or loss of the first or second inferior molar, when there is a third healthy molar that is included or embedded, in a favourable position and with conical roots. Extraction of this molar should be atraumatic, the periodontium should be preserved and the remains of the pericoronary sack eliminated. Preparation of the new socket should be done by eliminating the alveolar bone with a rounded, steel drill or tungsten with extensive irrigation.

• Sufficient space between teeth to allow for the placement of the molar. A little stripping can be carried out if necessary. Correct occlusion with antagonist.

• Sufficient bone height so as not to damage the dental nerve.

Dental Re-implantation

These are emergency cases that go to a dental practice or to a hospital. Youngsters that have experienced dentoalveolar trauma and that have lost one or various teeth are typical cases. We do not cover this area in this report although we will mention briefly that dental re-implantation can be carried out if the tooth and the alveolus are clean, and if parents have been correctly advised about the possibility of failure. The avulsed tooth should be deposited in sterile saline serum, and the alveolus should be cleaned with a spoon-shaped instrument in order to eliminate coagulation remains. The alveolus should be checked to confirm that it is complete undamaged with an intra-oral x-ray, and the tooth is then placed in its position. Ideal fixation would be with a little composite on neighbouring teeth and protection with Peripac.

Repositioning of incisors³

• Lateral superior incisors, palatally positioned or with vestibular inclination, providing all other teeth have correct occlusion.

• Sufficient space between the central incisor and the canine even though a small amount of stripping may have to be carried out in order to reposition the tooth.

• Sufficient inter-radicular space on the bone, visible in the orthopantomography, so as not to damage the roots of adjacent teeth.

• Age is not a determining factor as the dental movement is done as a segment, following an osteotomy.

• On occasions we have been able to move two teeth at once with good results.

Surgical technique

As with all surgical operations the patient will obviously not be free of postoperative discomfort, and a series of preand postoperative instructions have to be strictly followed. Antibiotic and anti-inflammatory protection⁷ will be needed, as well as a liquid-soft diet, and the patient has to realize that during the adaptation period he cannot play sport, or indulge in strenuous activity, nor smoke nor drink alcohol, and he will have to avoid chewing until the process has been concluded. Any change to these guidelines could lead to results giving little satisfaction or none at all.

Surgical manipulation of teeth has, in general, basic connotations which are valid for any oral surgery, and other more specific characteristics that we will discuss.

These types of procedures, under the prism of maxillofacial surgery, can be included in the framework of minor surgery, as they can be carried out with local anaesthetic on a day patient basis, their duration is under an hour, and no additional tests nor any other type of examination are required.

This does not mean to say that the person carrying out this surgery does not have proper training. For such is the case, that even in the ambit of maxillofacial surgeons, many of them should know the specific, technical aspects of this surgery in order to execute it correctly.

These interventions should be carried out in a suitable operating room for oral surgery, with truncal and infiltrative anaesthesia, according to each case, and if possible with the help of pre-or intraoperative sedation. A sterile area is prepared, similar to that used in implantology, with rotating apparatus, a handpiece with tungsten drill, and a turbine drill for fissures in order to perform a corticotomy. Irrigation carried out with sterile saline serum taking care not to heat the bone.

The mucoperiosteal flaps will be ample, and these incisions will be away from the osteotomies. An effort should be made to ensure that the separation of the mucoperiosteum should be cleanly done with no tears. In order to avoid harming them the separators of the assistant should be used.

Not touching the radicular area of the teeth with the drills or with the fingers so as not to harm the periodontal ligament is of fundamental importance. And, if we have to take the tooth out of the mouth, we should do this for as short a period as possible, and during this interval it should be placed in sterile serum.

Autotransplantations

In the case of embedded canines, normally a palatine flap will have to be carried out in order to reach the tooth (Fig. 1)⁸. The bone necessary to permit extraction will be removed with the use of a hand-held instrument. It is advisable to have a bone filter so as to be able to reuse it at the end for filling in defects. With extreme care we will expose the crown of the canine, and we will look for support so that the tooth can be moved with the aid of straight stabilizers. So as not to fracture the root, movements should be very controlled. Once the extraction has been achieved, the tooth is deposited in serum, and we will start making the «neo-alveolus», with the aid of a rounded, straight drill and with much irrigation. The tooth is then tried in its new position making sure that the root neither touches nor is pressed against the bone surrounding it, but rather that a space is left between them. This will be occupied by the clot which will subsequently be formed and which will turn into a mature alveolar bone and regenerate the periodontal ligament.

The crown will be secured by means of friction between the lateral incisor and the premolar, and the interproximal surfaces will be shaped until it is in an adequate position with correct occlusion. Following this we will suture the flaps with 5/0 type blanket stitches, rinse with saline serum and secure the tooth. It is of vital importance that there is no contact between the tooth that has been transplanted with its antagonist in all mandibular movements. Splinting^9,10 for ten days can be done with Peripac (Fig. 2) and after this a fluid composite can be used for another week.^11-13 Antibiotics, anti-inflammatory and gastric protection are prescribed. A liquid diet and mouthwashes with Chlorhexidine are recommended for the first two weeks. It is important for the health of the gums to start massaging them with a surgical brush as soon as the Peripac is removed (Figs. 3 and 4). During the next two weeks a very soft diet is recommended together with gingival massages and a tooth guard is provided.^14,15

The guidelines for the autotransplantation of molars are similar to those of canines, but splinting time is inferior as there is better primary stability (Figs. 5,6,7 and 8).

Repositioning

What we are most frequently likely to find is a superior lateral incisor displaced towards the palatine because of lack of space (Figs. 9 and 10).³ Once the flap has been lifted, with a fine tipped felt pen we draw the lines of the osteotomy which will go between the teeth with the fundamental objective of not damaging the roots of the neighbouring teeth. With a turbine and a long, fine, Tungsten drill we mark out the osteotomy (Fig. 11). We then go deeper into the vestibular bone until the palatine bone is reached. Two perpendicular lines of the osteotomy are traced, parallel to the root of the mesial tooth and distal tooth and a third horizontal supra-apical line. Following the osteotomy, with a fine, narrow chisel we start moving the segment of bone.¹⁵ With a diamond drill we carve the interproximal surfaces of the teeth so that when the segment is moved the transplanted tooth is perfectly positioned between the neighbouring teeth. This movement, which we started with the chisel, we finish with our fingers. Once in proper occlusion, we suture and immobilise the area, but on this occasion for a month, in order to ensure that a bone callus is formed in the area of the osteotomy. The guidelines for hygiene and treatment are the same for all proceedings (Fig. 12).

Results

It can be deduced from the three work areas of Table 1 that in the autotransplantation of canines and premolars, a success rate of 86,4% was achieved in 44 of the cases reviewed in the last two years; in the case of autotransplantation of molars, there was a 100% success rate in the 16 cases reviewed in the last two years. Repositioning was 100% successful in the 21 cases controlled over the same period.

Discussion

Surgical treatment for dental malpositions is a very limited practice in our country in private clinics as well as in hospitals. We believe the reasons behind this are the following:

• Lack of training in the Faculties of Odontology as these areas are not covered sufficiently in the programmes of Surgical Pathology. Professionals therefore do not have access to training in the technique and consequently they are not able to develop it later in the clinic.

• On a hospital level, future maxillofacial surgeons, during their formation as resident doctors, only have contact with dentoalveolar traumatology, which is insufficient for carrying out these types of interventions successfully.

• There is a lack of post-graduate training as a result of the former, which implies that there is a void in this field of surgical therapy. The lack of space is currently solved through orthodontia and prostheses, instead of the solutions previously mentioned.^16,17

• The considerable development in dental implants over the last years completes the circle, and publications on this issue are practically nonexistent.^6,18

• The splints we use are semi-rigid (Sutura and Peripac), coinciding with other professionals who corroborate that complete immobilization of the transplanted tooth encourages later rhizolysis or anquilosis.^9,10

When an osteotomy is performed of the alveolar segment during dental repositioning in which mini-plates are not used, we should secure the tooth we have moved to neighbouring teeth using a wire and composite.

Teeth should be surgically devitalised only in the event of there being a pathological necessity for doing so.

In spite of all this, we feel that surgical treatment of dental malpositions is a practice with a predictable and good prognosis, as demonstrated in this report, and that it is supported by other publications in international magazines.^2,5,6,16-19

Conclusions

1. There is no reason for replacing a lower primary molar of a young person with a fixed prosthesis supported either by the tooth or by an implant, if there is an embedded third molar, unless there is a lack of knowledge regarding the transplantation the molar in question.^1,5

2. There is no reason for extracting an embedded healthy canine and substituting it with a prosthesis supported by an osteointegrated implant. This tooth is the best implant that we can fix in our patient, in addition to it being more economical for the patient.

3. The repositioning of a superior lateral incisor can be done in just one surgical act with a duration of 40 minutes on an outpatient basis, which avoids orthodontic treatment for a year or more.^3,19

4. Based on the results our work group has obtained, we are able to confirm that the reasons given against these treatments, lack a scientific base, and those responsible for putting together training programmes should inform themselves and include them in the subjects of study, post-graduate courses and training courses. With correct surgical training, an atraumatic technique and careful case selection, surgical movement of teeth on an outpatient basis, with local anaesthesia, constitutes an option for treating patients with a favourable prognosis. It can be said that the old idea that dental transplantation is equivalent to rhizolysis and loss of the treated tooth belongs, in our country, to medical history.

References

1. Andreasen JO. Reimplantación y Trasplante en Odontología. Buenos Aires, Argentina: Ed. Médica Panamericana        [ Links ]

2. Peñarrocha MA, Peñarrocha M, García Mira B. Transplantes dentales, una alternativa en el tratamiento quirúrgico-ortodóncico de los dientes incluidos. Arch Odontoestomatol 2003;19:245-51.         [ Links ]

3. Pérez Fernández F, Jiménez Burkhardt A. Reubicaciones dentales. Rev Europ Odont1995;7:273-6.         [ Links ]

4. William M. Northway, Sydney Konigsberg. Autogenic tooth transplantation. Am J Orthod1980;77:146-62.         [ Links ]

5. Josefsson E, Brattstüm V, Tessjö Ulf, Valerius Olsson H. Treatment of lower second premolar agenesis by autotransplantation: four year evaluation of eighty patients. Acta Odontol Scan 1999;57:111-5.         [ Links ]

6. Czochrowska EM, Stenvik A, Bjorn Album and Bjorn U. Zachrisson. Autotransplantation of premolars to replace maxillary incisors: A comparison with natural incisors. Am J Orthod Dentofacial Orthop 2000;118: 592-600.         [ Links ]

7. Patrikiou AK, Katsavrias EG. Reposicionamiento de caninos maxilares anquilosados mediante osteotomía segmentaria. J Clin Orthod 1995;29:625-8.         [ Links ]

8. Medina Vega LD, Portal Fernández W, Ruiz Hernández A, Martín Pino J, Peydro Herrero M. Transplante autólogo de dientes retenidos: estudio de 10 años. Rev Esp Cirug Oral y Maxilofac 2003;25:85-9.         [ Links ]

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10. Gerard E, Membre H, Gaudy JF, Mahler P, y cols. Functional fixation of autotransplanted tooth germs by using bioresorbable membranes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:667-72.         [ Links ]

11. Magheri P, Grandini R, Cambi S. Autogenous Dental Transplants: Description of a clinical case. Int J Periodontics Restorative Dent 2001;21:367-71.         [ Links ]

12. Hans Ulrik Paulsen. Autotransplantation of teeth in orthodontic treatment. Am J Dento Orthop 2001;119:336-7.         [ Links ]

13. Khongkhunthian P, Chantaramungkon M, Waranywwat S. The treatment of an avulsed maxillary central incisor by transplantation of an embedded mandibular premolar. Dent Traumatol 2002;18:335-8.         [ Links ]

14. Bjerklin K, Bennet J. The long-term survival of lower second primary molars in subjects with agenesis of the premolars. European Journal of Orthod 2002;22:245-55.         [ Links ]

15. Tsukiboshi M. Autotransplantation of teeth: requirements for predictable success. Dt Traumatol 2002;18:157-80.         [ Links ]

16. Slagsvold O, Bjercke B. Applicability of autotransplantation in cases of missing upper anterior teeth. Am J Orthod 1978;74:410-21.         [ Links ]

17. Schatz JP, Joho JP. Indications of autotransplantation of teeth in orthodontic problem cases. Am J Orthod Dentofac Orthop 1994;106:351-7.         [ Links ]

18. Sagne S, Lennartsson B, Thilander B. Transalveolar transplantation of maxillary canines. Am J Orthod Dentofac Orthop 1996;90:149-57.         [ Links ]

19. Isaacson RJ, Strauss RA, Bridges-Poquis A, Deluso AR, Lindaver SJ. Moving ankylosed central incisor using orthodontics, surgery and distraction osteogenesis. Angle Orthodontist 2001;71:411-8.         [ Links ]